Theme:Treatment of Acne

ADianette
BNo treatment
COral retinoids
DOral tetracyclines
ETopical benzoyl peroxide
FTopical retinoic acid
GTopical tetracyclines
Select the most appropriate treatment for the following
patients presenting with acne.
A 17-year-old female presents with troublesome facial
acne with mild hirsutism. She was recently diagnosed
with polycystic ovarian syndrome.

Correct

A 55-year-old male presents with redness of both

cheeks. He is diagnosed with acne rosacea.

Correct

A 15-year-old girl presents with troublesome facial acne

which tends to be worse around the time of her periods.
There is mild acne around her chin and cheeks.

Correct
Treatment of mild to moderate acne vulgaris is best started with topical therapy such
as benzoyl peroxide. This therapy is usually effective and would be the most
appropriate choice for the 15-year-old. The young woman with PCOs would best be
treated with dianette where the cyproterone acetate has antiandrogenic actions
reducing sebum production plus having an effect on the hirsutism. In acne rosacea ,
the most appropriate therapy is a long course of tetracyclines

Theme:Fungal Skin Infections

ACandida
BFavus
CKerion
DOnychomycosis
EPityriasis versicolor
FTinea capitis
GTinea cruris
HTinea maanum
ITinea pedis
JTinea incognito
For each patient below, choose the single most likely
diagnosis from the above list of options. Each option
may be used once, more than once or not at all.

A 55-year-old diabetic presents with a rash in the

submammary folds and groin. Multiple satellite pustules
and papules can be seen beyond the edge of the original
rash.

Correct
Candidal infections are common in diabetics and may
be the presenting symptom. In candidal intetrigo
pustules extend beyond the margins of the rash (satellite
lesions) unlike dermatophyte infections.

A 15-year-old boy of Middle Eastern origin is seen with

large yellowish white crusts on the scalp associated with
hair loss and areas of scarring.

Correct
Another type of tinea capitis, favus is rare in the UK
and USA but is prevalent in the Middle East, South
Eastern Europe, the Mediterranean and Africa. Cup
shaped crusts called scutulae form around loose hairs.
The lesion may resemble a cradle cup and scarring
alopecia is common.

A 45-year-old woman presents with a scaly and itchy

rash in one palm. The scaling is more prominent in the
palmar and finger creases.

Correct
The dry and scaly form of tinea maanum which is the
more common type usually affects only one hand. The
feet should be examined as they are invariably infected.
Favus is a skin disease caused by a fungus which mainly affects the scalp and less
commonly yhr nails. When the lesions fall off the portion of scalp affected is usually
hairless.

Theme:Diabetic foot ulcer

AAmytriptyline
BBelow knee Amputation
CCarbamazepine
DChange foot wear
EGabapentin
FIV Antibiotics
GLarval therapy
HOral antibiotics
ISurgical debridement
JTopical Fucidin
KTopical steroids
Choose the SINGLE most appropriate treatment from
the list.

The figure illustrates the appearance of a patient's foot.

He complains of parasthesia in his feet and has been
feeling hot and sweaty.

Incorrect - The correct answer is IV Antibiotics

Diabetes results in defective responses to infection and
the presence of an infected ulcer in the setting of
peripheral neuropathy should be treated very seriously.
Protracted antibiotic therapy is often required and
preventative measures need to be taken to prevent
recurrence, including attention to foot care and
provision of adequate footwear. Failure to respond to
antibiotic therapy may require surgical debridement or
even amputation. Topical Larval therapy has been used
with some effect and may reduce the need for surgical
removal of necrotic tissue.

. Theme:Skin lesions

AAccessory nipple
BBasal cell carcinoma
CBasal cell papilloma (seborrhoeic keratosis)
DBenign compound naevus
ECaf au Lait spots
FCampbell de Morgan s spots
GDermatitis artefacta
HKaposi s sarcoma
IKeloid scar
JKeratoacanthoma
KLipoma
LMalignant melanoma
MMolluscum contagiosum
NSpider naevus
OSquamous cell carcinoma
PViral wart
The following patients present to the clinic with a skin
lesion which is causing them concern. Choose the most
likely diagnosis from the list given above.
A 40-year-old white woman, a travel courier, notes a
painless lesion on her calf. This lesion is brown, with
irregular margins, measuring 1.5cm in diameter. The
lesion is itchy, and she complains that it has bled.

Correct
This is the classical presentation of a malignant
melanoma. Factors which alert one to a melanoma are
pigmentation, increasing size, bleeding and itchiness.

A 29-year-old man, working as a journalist, with a

history of HIV infection, presents with a cluster of
pearly like lesions, each measuring 0.3cm in diameter,
in the beard area.

Correct
Molluscum contagiosum is a benign DNA pox virus.
Cell-mediated immunity is important in modulating and
controlling the infection as children and HIV-infected
patients have more widespread lesions.

A 35-year-old Afro-Caribbean launderette-manageress

requests excision of a firm nodule in the skin over the
sternum. She states that she previously had surgery at
this site.

Correct
Keloid scarring is more common in patients of AfroCaribbean origin. It consists of a benign overgrowth of
fibroblastic tissue. Keloids classically appear on the
upper back, chest and deltoid region and follow skin
injury, e.g. surgery, ACNE, but may arise
spontaneously.

A 75-year-old white man, a retired clerk, has several

brown, well-demarcated, papillary lesions, typically
about 2cm in diameter on his trunk. He states that some
of these lesions have been rubbed off by his belt.

Correct

A 75-year-old white man, a retired builder, presents

with a white lesion on the cheek. This has a central
ulcer 0.5cm in diameter, with rolled edges and adjacent
telangiectasia. The lesion has been present for three
months.

Correct
Basal cell carcinoma are classically slow growing, with
rolled edges, occur on the face, and are associated with
telangiectasia, and increase with advanced age.

Theme:

An examination finding in a diabetic

AAcanthosis nigricans
BCellulitis
CChronic fungal infection
DDermatits herpetiformis
EErythema nodosum
FGranuloma annulare
GNecrobiosis
HNecrolytic migratory erythema
IPemphigus
JPemphigoid
KPyoderma gangrenosum
Choose the SINGLE most likely option from the list.

From the above list of options select the diagnosis for

the above figure, which illustrates the appearance of the
axilla of a patient with type 2 diabetes

Correct
Acanthosis nigricans is a hyperpigmented overgrowth
of the epidermis, usually in the flexural areas of the

groin, axilla and neck. It is associated with insulin

resistance a possible mechanism being the effect of
raised insulin concentrations acting on IGF-1 receptors
in skin promoting growth.

Theme:A rash in a male diabetic

AAcanthosis nigricans
BChronic fungal infection
CDermatitis herpetiformis
DErythema marginatum
EErythema multiforme
FErythema nodosum
GGranuloma Annulare
HNecrobiosis
INecrolytic migratory erythema
JPemphigoid
KPemphigus
Choose the SINGLE most likely option from the list.

From the above list of options select the most

appropriate diagnosis to account for this appearance on
the legs of a 50-year old patient with glycosuria.

Correct
Necrobiosis is strongly associated with diabetes. The
shin is the usual site. Ulceration occurs in around 25%
of lesions and the lesions are either partially or
completely anaesthetic.

Theme:Dermatological Treatments
AAntifungal agents
BAntihistamines
CAzathioprine
DEmollients
EIsotretinoin

FLaser therapy
GPotent topical corticosteroids
HPUVA therapy
ISystemic corticosteriods
JWide excision
For each of the patients below, choose the single most
likely treatment from the above list of options. Each
option may be used once, more than once or not at all.
A young aspiring pop musician presents with
erythematous papules and nodules on his face, uppper
chest and upper back. You also notice some cysts and
scarring.

Incorrect - The correct answer is Isotretinoin

Isotretinion (roaccutane) is now the standard treatment
for severe acne. It is teratogenic and a pregnancy test
and the use of contraception in women is mandatory
before treatment.

A 60-year-old woman with a 5 year history of psoriasis

has been admitted for in patient treatment three times in
the last 8 months. Presently she is very ill and febrile
and 90% of her skin is fiercely red and scaly.

Incorrect - The correct answer is PUVA therapy

PUVA is a recognised treatment for unstable psoriasis
requiring frequent in patient treatments and also for
erythrodermic psoriasis.

A 7-year-old girl is brought to see you because she has

mild red patches in both cubital and popliteal fossae
which are not too itchy. Her mother is asthmatic.

Incorrect - The correct answer is Emollients

The likely diagnosis is atopic dermatitis and all patients

require emollients.

A woman presents with a large red patch over her cheek

and lower jaw, which she has had since infancy.

Incorrect - The correct answer is Laser therapy

Lasers (pulse-dye) are now the standard treatment for
port wine stains with a high success rate. They can also
be used for haemangiomas, telengiectasia, spider naevi
and tattoo removal.

A woman of Welsh descent presents with a hyper

pigmented swelling on her right leg. She is concerned
that the size has doubled over the past two months.

Correct
The prognosis of malignant melanoma is directly
related to the depth of tumour invasion. Surgical
excision is the treatment of choice although adjunctive
therapy may be required in case of metastases.

Theme:Lumps and Bumps

ABartholin's cyst
BBerry aneurysm
CBranchial cyst
DEpididymo-orchitis
EErythema nodosum
FFemoral hernia
GGanglion
HGerm cell tumour
IHeberden's node
JHiatus hernia
KHydrocoele
LInguinal hernia

MLipoma
NLymphadenopathy
ONeurofibroma
PPalpable gall bladder
QPapillary carcinoma of thyroid
RParathyroid adenoma
SParaumbilical hernia
TPleomorphic adenoma of parotid
URheumatoid nodule
VSebaceous cyst
WThyroglossal duct cyst
Each of the following patients presents with a swelling
on clinical examination. Select the most likely diagnosis
from the list above.
A woman aged 73 years presents with a painful swelling
in the right groin, measuring 3cm in diameter. It lies
below the inguinal ligament, and medial to the femoral
artery. A plain x-ray examination of the abdomen
reveals dilated loops of small bowel

Correct
Femoral herniae account for 4% of all herniae. They are
most common in elderly women. They may strangulate,
and the dilated bowel loops in this case may suggest
bowel obstruction.

A man aged 25 years presents with an enlarging

painless swelling in the left side of the scrotum. It does
not transilluminate. Ultrasound scan of the lower
abdomen reveals lymphadenopathy along the external
iliac artery; a chest X-ray is normal

Correct
This unfortunate gentleman has a testicular tumour until
proven otherwise given the intrabdominal
lymphadenopathy, and a germ cell tumour is the likely
candidate in this age group. Nither Epididymo-orchitis
nor hydrocele cause intra-abdominal lymphadenopathy.

A woman aged 24 years presents with a smooth painless

swelling, 2cm in diameter, in the midline of the neck
just below the hyoid bone. An ultrasound scan shows
that the lesion is cystic.

Correct
A cystic midline swelling of the neck which is painless
in a young person suggests thyroglossal cyst. They may
occur on the chest wall and axilla and rarely elsewhere.
It's cystic nature differentiates it from lipoma and
neurofibroma.

A man aged 40 years develops a recurrence of a painless

swelling on the wrist; it is not tethered to the skin. X-ray
of the wrist reveals no bony abnormality.

Correct
A ganglion is a small cyst filled with synovial fluid,
most commonly found on the dorsal aspect of the wrist.
It is not tethered to the skin and does not change in size
rapidly.

A man aged 51 years notices a painless swelling, 1.5cm

in diameter, on the back of the neck; it is tethered to the
skin. An x-ray of the cervical spine is normal.

Correct
Sebaceous cysts are normally found on the scalp, nape
of the neck, face, ears and genitals. Cysts form when the
release of sebum from sebaceous glands in these regions
is blocked.

On examination of lumps...

Theme:Skin and subcutaneous lesions

ABasal cell carcinoma
BBowens disease
CDermatofibroma
DKaposis sarcoma
EKeratoacanthoma
FLentigo maligna
GMarjolins ulcer
HNodular melanoma
ISpider naevus
JSquamous cell carcinoma
Which of the lesions listed above best matches the case
scenarios described below?
A 64-year-old woman is referred by her GP with an
itchy red-brown lesion on her cheek. It has been present
for many months and has been growing slowly. On
examination there is a 1 x 0.5 cm lesion with a crusty
surface. No other lesions are seen and there is no
lymphadenopathy.

Incorrect - The correct answer is Bowens disease

Bowens disease is a pre-malignant lesion for squamous
cell carcinoma. UV exposure is the main risk factor for
Bowens disease. When detected it should be treated as
per a SCC as there are often small foci of malignant
cells within the areas of Bowens disease.

A 45-year-old woman is referred with a lesion on her

cheek. On examination you see it is raised above the
level of the surrounding skin, has an irregular surface
with smooth sides, central umbilication and a crusty
core.

Incorrect - The correct answer is Keratoacanthoma

Keratoacanthomas are benign lesions that are often

mistaken for BCC/SCC. They occur as a result of
hyperplasia of hair follicles and are most common in
sun exposed areas. They tend to regress spontaneously
over a period of 6-12 months without the need for any
treatment.

A 70-year-old woman is referred with a 3 x 2 cm

pigmented brown-black lesion on her right temple. On
examination the lesion has an irregular edge but has a
smooth flat surface. No lymphadenopathy is palpable.

Incorrect - The correct answer is Lentigo maligna

Lentigo maligna or Hutchinsons freckle occurs in sunexposed areas and is more common in females. It is a
melanoma in-situ and as such carries a much better
prognosis than the other more common varieties of
melanomas nodular and superficial spreading.

A 34-year-old male intravenous drug-abuser is seen in

the clinic with several new red-brown nodules on his
limbs. He has also recently been treated for an
opportunistic pneumonia and his prescription includes
AZT.

Correct
Kaposis sarcomas are a common manifestation of HIV
infection and the lesions may be the presenting feature.
There is no specific treatment required in terms of
resection but the lesions often improve with antretroviral therapy.

A 53-year-old man is seen in the emergency department

with haematemasis. On examination, in addition to
hepatosplenomegaly, he is noted to have clubbing and
multiple small red lesions over his torso that blanch
with pressure and then fill from the centre outwards.

Correct
Spider naevi are a form of telangiectasis and may occur
in the general population on the torso and head & neck.
When >5 are present they are considered pathological
and are often associated with chronic liver disease. No
treatment is indicated but their presence may stimulate
investigation for liver disease.

Theme:Causes of purpura
Aamyloidosis
BCushing's disease
Cdisseminated intravascular coagulation (DIC)
DEhlers-Danlos syndrome
Ehaemophilia
FHenoch-Schonlein syndrome
Giatrogenic
Hidiopathic thrombocytopenic purpura (ITP)
Iparoxysmal nocturnal haemoglobinuria (PNH)
Jscurvy
Kthrombotic thrombocytopenic purpura (TTP)
For each presentation, choose the SINGLE most likely
cause from the above list of options. Each option may
be used once, more than once, or not at all.
A 45-year-old asthmatic has a moon-like facies and
truncal obesity. He complains of easy bruising and thin
skin.

Incorrect - The correct answer is iatrogenic

This patient has Cushing's syndrome from steroid
treatment for his asthma (iatrogenic). The term
Cushing's disease is reserved for pituitary dependent
Cushing's syndrome, which accounts for 80% noniatrogenic cases. The other 20% is caused by adrenal
adenoma and ectopic ACTH syndrome (eg small cell
bronchogenic carcinoma).

A 35-year-old woman presents with purpura, fever,

haemolytic anaemia, microvascular thrombosis, renal
failure and mild stroke. Blood film shows fragmented
red cells and clotting screen is normal.

Correct
Thrombotic microangiopathies are characterized by
microangiopathic haemolytic anaemia,
thrombocytopenia, microvascular thrombosis and
multiple organ dysfunction. TTP has a peak incidence
between 30-40 years of age, whilst haemolytic uraemic
syndrome (HUS) occurs mainly in young children after
a viral or gastrointestinal infection. TTP may occur
following cytotoxic drugs eg mitomycin or cyclosporin,
be associated with SLE, pregnancy or oral contraceptive
use. However, in most cases there is no known cause.
Unlike DIC, clotting screen including fibrinogen level,
fibrinogen degradation products and thrombin time is
almost always normal in TTP/HU

A 56-year-old vagrant presents with perifollicular skin

bleeding and prolonged bleeding time.

Correct
Poor nutrition has contributed to his Vitamin C
deficiency, which typically with excessive bleeding
(gums, GI tract and brain). Perifollicular bleeding is
also common. Bleeding time is prolonged. Diagnose by
measuring leucocyte vitamin C level.

A 35-year-old man has hyperextensible joints and

elastic skin. He also has purpura, and pseudotumours
over his knees and elbows.

Correct

This syndrome is characterized by abnormal velvety

hyperelastic skin which heals poorly (producing fishmouth wounds), hyperextensible joints and lax
ligaments. Pseudotumours are organization of
haematomas from injuries, which undergo fatty
degeneration before calcification. Other features include
recurrent hydrarthrosis, repeated falls, spontaneous
pneumothorax, dissecting aneurysms and mitral valve
prolapse.

A 20-year-old man presents with colicky abdominal

pain, arthritis and polyarthritis following a chest
infection. He also has purpura over his buttocks and
legs.

Correct
The clinical features of HSP include arthritis, urticarial
rash/purpura over the extensor aspects of arms and legs,
GI symptoms (colicky pain, malaena, haematemesis,
obstruction and intussusception) and glomerulonephritis
(mesangial proliferative GN- macroscopic haematuria
and nephrotic syndrome more common in adults).
Confirm by immunofluorescence for IgA and C3 in skin
lesions/glomerular mesangia.

Information on types of purpura...

Theme:Causes of erythema nodosum
Acoccidioidomycosis
Bcrohn's disease
Cleprosy
Doral contraceptive pill
Erheumatic fever
Fsarcoidosis
Gstreptococcal infection
Hsulphonamides
Itoxoplasmosis
Jtuberculosis
Kulcerative colitis

For each presentation, choose the SINGLE most likely

cause from the above list of options. Each option may
be used once, more than once, or not at all.
A 46-year-old woman with a history of rheumatoid
arthritis, controlled on treatment, presents with
erythema nodosum.

Incorrect - The correct answer is sulphonamides

Sulphasalazine is a combination of 5-aminosalicylic
acid and sulphapyridine, used as a disease-modifying
drug in rheumatoid arthritis, in mild/moderate ulcerative
colitis and maintainance of remission, and active
Crohn's disease. Side-effects of sulphonamides include
rashes (including erythema nodosum), Stevens-Johnson
syndrome, renal failure, blood dyscrasia (bone marrow
suppression and agranulocytosis) and oligospermia.

A 55-year-old man from the Middle-East presents with

facial coarsening with 'leonine facies', and gross
thickening of the ear-lobes. He has recently developed
erythema nodosum.

Correct
Leprosy is caused by acid-fast bacillus Mycobacterium
leprae. The two extreme ends of the spectrum are
tuberculoid leprosy (localized disease because of
marked immunological response) and lepromatous
leprosy (generalized disease because of impaired cellmediated immunity). Two forms of lepra reactions
(immunological mediated reactions) are recognized.
Type II lepra rection (erythema nodosum leprosum) is a
type III hypersensitivity reaction seen in lepromatous
end of the spectrum (50% with treated lepromatous
leprosy (LL), and occasionally in untreated LL or
treated borderline lepromatous leprosy). It is
characterized by fever, arthralgia, painful neuritis,
erythema nodosum, iridocyclitis, acte lymphadenitis
and epididymo-orchitis. Type I reaction occurs
frequently in treated borderline tuberculoid (BT)
leprosy, borderline leprosy (BB), and borderline

lepromatous leprosy (BL). It is a type IV

hypersensitivity reaction characterized by acute
swelling and inflammation of existing lesions. Painful
neuritis may also occur.

A 19-year-old woman develops erythema nodosum

shortly after developing a sore-throat and fever.

Correct
This patient has a streptococcal throat infection, causing
erythema nodosum.

A 42-year-old woman presents with a recent onset of

painless, smooth and mobile cervical lymphadenopathy,
and erythema nodosum. There is evidence of
lymphocytosis, with atypical lymphocytes on the blood
film.

Incorrect - The correct answer is toxoplasmosis

Toxoplasmosis is caused by intracellular protozoon,
Toxoplasma gondii. It can be difficult to distinguish
from infectious mononucleosis, except in
toxoplasmosis, there is no pharyngitis, oral petechiae or
splenomegaly. Serological tests can be used to confirm
acquired infection. Paul-Bunnell (Monospot) test is
negative.

A 35-year-old man is admitted with bilateral hilar

lymphadenopathy, erythema nodosum and mild
breathlessness.

Correct

He has acute sarcoidosis, which has a good prognosis.

80% settle spontaneously and have a normal chest Xray after 1 year.

Everything you want to know about Erythema

Nodosum...
Next question

Theme:Diagnosis of skin lesions

Adermatitis herpetiformis
Berythema nodosum
Cpyoderma gangrenosum
Dpsoriasis
Epemphigus
Ferythema multiforme
Gpemphigoid
Hlichen planus
Ipretibial myxoedema
Jpityriasis versicolor
Keczema
For each case below, choose the
SINGLE most likely cause from the
above list of options. Each option may be
used once, more than once, or not at all.
A 30-year-old woman has a long history
of plaque-like lesions on the extensor
aspects of her elbows, and also pitting of
her nails.

Incorrect - The correct answer is

psoriasis
There is a tenfold increase in speed of
epidermal cell proliferation in psoriasis.
Commonest lesion is plaque psoriasis.
Others include guttate psoriasis, palmar
and plantar psoriasis, flexural psoriasis

and pustular psoriasis. Pitting of nails

and onycholysis is characteristic.

A 45-year-old man presents with a one

year history of pruritis. Examination
revealed widespread excoriations with
vesicles, most of which are ruptured. He
is on a gluten free diet.

Correct
Dermatitis herpetiformis occurs mainly
between 20-50 years of age and is almost
always associated with coeliac disease.
Lesions are extremely pruritic. Direct
immunofluorescence showing IgA
deposits in unaffected skin is diagnostic.
Treatment is gluten free diet and
dapsone.

A 72-year-old woman complains of a six

month history of tense blisters forming
over the trunk and lower limbs. There are
no lesions in the mouth.

Correct
Site of blister is at basement membrane
between epidermis and dermis (unlike
pemphigus where site is in epidermis);
therefore blisters less likely to rupture.
Mucosal lesions are uncommon in
pemphigoid. Biopsy shows IgG and
complement at basement membrane
zone. Treatment is with systemic
steroids, and azathioprine for steroid
sparing effect.

A 23-year-old woman has a severe sore

throat and also painful, raised red lesions
in the front of her shins.

Correct
Erythema nodosum is an acute
panniculitis that produces painful
nodules on the shins. Streptococcal
throat infection is the cause in this case.

A 40-year-old woman has noticed

elevated skin lesions with a peaud'orange appearance over her lower legs.
She has a history of thyroidectomy.
Examination revealed exophthalmos.

Correct
Pretibial myxoedema occurs in about 5%
of patients with Graves disease. The
superficial layer of skin is infiltrated with
hyaluronic acid.

Theme:Vaginal discharge.
AAllergic
BBacterial vaginosis
CChild sex abuse
DForeign body
EPinworms
FRectovaginal fistula
GTumour
HVulvovaginitis, infectious
IVulvovaginitis, non-specific
For each scenario choose the most likely
diagnosis:

A 4-year-old girl presents with persistent

scratching of her anus. Perineal
examination is unremarkable.

Correct
Perianal itching is usually due to
pinworms (threadworms). This can be
confirmed by a sellotape test, where a
strip of sellotape is placed at the anal
margin on waking and examined for
worms.

A 4-year-old girl presents with vaginal

irritation and scanty discharge. On
examination she has minimal perineal
redness.

Correct
Vaginal irritation with redness is
common as girls learn to wipe
themselves after defaecation and as the
skin is thin and sensitive at this age.
Avoidance of occlusion (eg plastic
pants), irritants (eg bubble bath) and
keeping the perineum dry usually results
in rapid resolution.

A 9-year-old girl presents with vaginal

irritation and offensive discharge. On
examination a mucopurulent discharge is
seen.

Incorrect - The correct answer is

Vulvovaginitis, infectious
Offensive mucopurulent discharge
suggests a significant infection, such as

chlamydia or gonorrhoea. Swabs should

be taken, including for these organisms.
If positive then child sex abuse has been
confirmed.

Theme:Nail changes
ABeaus lines
BClubbing
CKoilonychia
DLeuconychia
EMelanonychia
FOnychomycosis
GPitting
HSplinter haemorrhages
IYellow nail
Which of the nail changes listed above
may be seen in association with the
following patients conditions:

A 68-year-old woman is discharged from

hospital after a 2 month admission on
ITU with sepsis. She is weak and
complains of hair loss.

Correct

A 72-year-old female presents with

tiredness and weakness. On examination
she is pale and has a haemoglobin of 7.2
g/dl with an MCV of 68fl.

Correct

A 28-year-old male has a five year

history of well controlled ulcerative
colitis.

Correct
Nail changes are quite common in association with systemic diseases. Beaus lines are
horizontal ridges in the nail indicating retardation of nail growth at the growth plate.
Such an occurrence may occur in association with severe illness and a similar
situation occurs with the hair. Consequently the hair is brittle at this point and hair
loss occurs. Kolonychia, or spoon shaped nails are typical of iron defiency anaemia
low MCV, low Hb. It can also occur in association with trauma and the nail patella
syndrome. Ulcerative colitis like Crohns disease and cirrhosis is a GI cause of
clubbing.

Theme:Hair loss
AAlopecia areata
BAndrogenic alopecia
CCicatricial
DDrug induced
EHypothyroidism
FPsoriasis
GSyphilis
HSystemic lupus erythematosis
ITelogen effluvium
JThyrotoxicosis
KTinea capitis
Select the most appropriate diagnosis
from the list above for the following
cases who all present with hair loss
A 33-year-old woman presents with a
three month history of weight loss and
hair loss. She is a non smoker, receives
no medication and drinks little alcohol.
On examination she has a fine tremor of
the outstretched hands, lid lag and there
is mild generalised thinning of the scalp
hair.

Correct

A 33-year-old female is concerned

regarding hair loss. She has a past history
of Hashimotos thyroiditis for which she
takes 100 micrograms of thyroxine daily.
Examination is normal except for two
patches of hair loss of approximately
4cm and 3cm in diameter on the right
temporal scalp and at the occiput.

Incorrect - The correct answer is

Alopecia areata

A 33-year-old female presents with a 3

year history of oligomenorrhoea, hair
loss and hirsutism. She is a non smoker
and uses a Mirena coil for contraception.
On examination she is obese, has
acanthosis nogricans in the axilla and
back of neck, has some facial hirsutism
around the jawline and has temporal
recession of the hair line together with
hair loss at the crown.

Incorrect - The correct answer is

Androgenic alopecia
Hair loss is a common problem and it is important to first identify its location on the
scalp, nature and other associated dermatological or systemic signs. Thyrotoxicosis is
associated with hair loss but hair loss may also be exacerbated by thionamides.
Alopecia areata is an autoimmune condition associated patchy bald spots. This may
progress further into alopecia totalis with total body hair loss. The condition is
associated with other autoimmune conditions such as hypothyroidism and in this
patients case the hair loss is not due to the drug therapy such as over-replacement or
under-replacement as there are no features of either mentioned on examination.
Polycystic ovarian syndrome is suggested by hirsutism, weight gain, acanthosis
nogricans and oligomenorrhoea. The Mirena coil would explain oligomenorrhoea but
is purely a distraction. PCOs is associated with hyperandrogenism and in this case the
temporal recession with thinning at the crown suggests androgenic alopecia i.e. male

Theme:RASHES
AStaphylococcal scalded skin syndrome
BRubella
CMeasles
DKawasakis disease
EImpetigo
FScarlatina
GInfectious mononucleosis
HHenoch Schonlein purpura
IMeningococcal infection
JStills disease (systemic onset juvenile
chronic arthritis)
Match the following descriptions of rash
with the illness for which they are the
most typical exanthem

A 5-year-old boy has a bright, red,

punctate, erythematous rash which
blanches on pressure, beginning in the
axillae with some perioral pallor and
relative facial sparing. The skin feels like
sandpaper. The rash fades and
desquamates on the hands and feet. A
thick white exudate develops on the
tongue which peels leaving a strawberry
tongue with prominent papillae.

Incorrect - The correct answer is

Scarlatina
This description is typical of Scarlatina
i.e. beta haemolytic streptococcal
infection. The rash may be confused with
that of Kawasaki disease. However,
desquamation occurs in late in
Kawasakis disease.

A maculopapular rash develops in a child

with sore throat and fever who has been
treated with ampicillin.

Correct
This is a known effect of giving
ampicillin during EBV infection.

A 3-year-old child presents with high

fever for 7 days, conjunctival injection,
fissuring of the lips and strawberry
tongue, erythema followed by
desquamation of the hands and feet, and
a macular rash over the trunk with
cervical lymphadenopathy.

Correct
There are major and minor features of
Kawasaki disease. High fever and
desquamation are typical

Theme:RASHES
AStaphylococcal scalded skin syndrome
BRubella
CMeasles
DKawasakis disease
EImpetigo
FScarlatina
GInfectious mononucleosis
HHenoch Schonlein purpura
IMeningococcal infection
JStills disease (systemic onset juvenile
chronic arthritis)
Match the following descriptions of rash
with the illness for which they are the
most typical exanthem.

A salmon-coloured, reticulate macular

rash develops mainly over the extensor
surfaces of the limbs in a 5-year-old boy
with swinging temperature; hot, swollen,
painful knees and left elbow and
palpable spleen. The ESR is 95. The
blood count, C-reactive protein and chest
X-ray are normal.

Incorrect - The correct answer is

Stills disease (systemic onset juvenile
chronic arthritis)
Salmon-coloured is the description
used to describe the rash of Stills
disease. The distribution is not that of
HSP which covers typically the buttocks
and limbs and is a purpuric rash.

A 12-year-old boy develops petechiae

and papules, some of which become
purpuric over his buttocks and legs,
associated with painful swollen knees.
There is microscopic haematuria on
testing. The platelet count is normal.

Correct
This is a description of HSP and the well
recognised complication of HSP
nephritis. A proportion of these patients
will develop progressive nephritis and
end stage renal failure.

A 5 day old girl has a high temperature

and is irritable. She has areas of
desquamation over her finger tips and in
the axillae. Her carer notices that her

skin blisters easily following minimal

contact.

Correct
SSSS results from infection with
staphylococci with the exofoliative toxin
A and B. These exotoxins cause
disruption to the epidermal layer by
interfering with intercellular junctions.
Mortality is up to 3% in children. The
desquamation occurs concomitantly with
the illness unlike Kawaskis disease and
Kawasaki disease does not occur in this
age group. There may be a history of
minimal skin trauma which provides a
port of entry for the organism.

Theme:Skin and subcutaneous lesions

ABasal cell carcinoma
BDermatofibroma
CGanglion
DKeratoacanthoma
ELipoma
FMalignant melanoma
GPyogenic granuloma
HSebaceous cyst
ISquamous cell carcinoma
Jvon Recklinghausens disease
Which of the lesions listed above best
matches the case scenarios described
below.
A 64-year-old park attendant is referred
with a slow growing ulcerated lesion on
the dorsum of his hand. On closer
inspection it has a raised everted edge.

Correct

An ulcerated lesion with an everted edge

is typical of an SCC, a malignant skin
lesion that typically arises on sunexposed areas of the body. The lesions
grow slowly and locally destroy tissue
but may also metastasise to lymph nodes.
Other predisposing factors include:
radiation exposure; pre-malignant
conditions (Bowens, senile keratosis,
lupus vulgaris, pagets disease); inherited
(xeroderma pigmentosum, albinism);
chronic irritation (Marjolins ulcer,
leukoplakia, varicose veins,
osteomyelitis sinus); infection (HPV 5 &
8).

A 43-year-old woman is seen with

multiple fleshy lesions over her torso and
several are catching on her clothing and
irritating her. In addition to these lesions
she also has numerous brown spots on
her trunk.

Incorrect - The correct answer is von

Recklinghausens disease
The combination of fleshy lumps which
are neurofibromas and caf au lait spots
(> 6 patches) is typical of von
Recklinghausens disease or
neurofibromatosis Type I (Type II =
acoustic neuromas and sparse skin
lesions). Other findings include multiple
freckles over the torso and axillae and
areas of depigmentation. May be
associated with: multiple endocrine
neoplasia IIb (medullary carcinoma of
thyroid & phaeochromocytoma); glioma;
and meningioma. It is autosomally
dominantly inherited. Symptomatic
lesions can be excised. There is a 10%
risk of malignant change.

A 60-year-old man presents with a nontender swelling on the dorsum of his left
wrist. It has been slowly growing over
many years and on examination is tense
and does not empty.

Correct
A ganglion is a benign lesion although it
remains uncertain as to whether it is a
tumour of the joint capsule/tendon sheath
or a degenerative process of these
structures. Ganglia are also seen over the
dorsum of the foot, flexor aspects of the
fingers and peroneal tendons. They can
be excised under local anaesthetic but up
to 1/3 recur.

A 13-year-old boy is seen in the clinic

with a 1cm bright red pedunculated
lesion on his hand which is encrusted
following a recent bleed.

Incorrect - The correct answer is

Pyogenic granuloma
Pyogenic granulomas are usually seen is
in children and young adults on the
hands and face and pregnant women
develop lesions on their lips and gums.
The name is a misnomer (initially
believed to be a granulation response to
infection) and they are in fact benign
capillary haemangiomas. The lesion
should be treated by curettage and
diathermy of the base.

A 23-year-old woman is seen with a 1 x

2 cm brown-purple lesion on the back of
her calf. On closer inspection it is
uniform in colour, has a smooth surface

and edges and is slightly elevated from

the surrounding skin.

Incorrect - The correct answer is

Dermatofibroma
A dermatofibroma is a benign skin
lesion. No treatment is required but there
is often patient anxiety over the presence
of a pigmented lesion and many request
their removal which can be done under
local anaesthetic.

Theme:Childhood viral infections

AAdenovirus
BCoxsackie
CCytomegalovirus
DEpstein barr
EMeasles
FMolluscum contagiosum
GMumps
HRotavirus
IRubella
JVaricella
For each patient with the group of
symptoms listed below, choose the
SINGLE most probable causative agent
from the above list of options. Each
option may be used once, more than once
or not at all.
A three-year old girl presents with a
macular confluent rash which appeared
initially behind the ears and has spread.
Over the previous five days she has had a
low grade fever, catarrh and
conjunctivitis. Her mother is vague about
her immunization history.

Correct

Measles is caused by RNA

paramyxovirus and occurs worldwide.
Outbreaks are common in areas with
high numbers of non immunized
children. Infection is transmitted via
respiratory droplets and incubation
period is 10-21 days. The prodromal
stage fever conjunctivitis, runny nose
and coughing lasts for five days.
Kopliks spots are bright red lesions with
a central white dot which appear on the
buccal mucosa. These are virtually
diagnostic. The typical macular
confluent rash appears on the face from
day 3-5 and spreads to the rest of the
body. Diagnosis is made from clinical
features, viral culture from lesions and a
grater than 4-fold rise in antibody titres.
Otitis media, pneumonia, meningitis and
very rarely several years after primary
infection subacute sclerosing
panencephalitis (SSPE).

A two-year-old infant boy is admitted to

hospital with vomiting, non bloody
watery diarrhoea and is dehydrated. It
emerges other children from his play
group have developed a similar illness.

Correct
Rotavirus is the most common cause of
severe viral gastroenteritis worldwide.
Infection is via the faeco-oral route and
often occurs in children aged between six
months to six years. This RNA virus
replicates in the intestinal mucosal cells
damages transport mechanisms leading
to salt and water depletion which results
in diarrhorea and vomiting. Diagnosis is
made from clinical features and culture
of virus from stools and also by
Polymerase chain reaction techniques.
Treatment is mainly re-hydration and
correction of any electrolyte imbalance.

A two-year-old boy is mildly unwell. His

mother has noticed vesicles in his mouth,
palms and soles of his feet.

Incorrect - The correct answer is

Coxsackie
Coxsackie A16 virus is the cause of
hand, foot and mouth disease
characterized by fever, sore throat and
ulcerating vesicles in palms, orophaynx
and on soles. Incubation period is 5-7
days and these heal without crusting.
Treatment is symptomatic.

A ten-year-old girl develops an itchy rash

which began on her trunkand has since
spread over the entire body. She travelled
to see her grandmother who was unwell
with a painful rash three weeks ago.

Correct
Varicella (Chicken pox) is transmitted by
respiratory droplets and contact with
somebody with shingles. Incubation
period is 14-21 days and following a
brief period of malaise, an itchy
papulovesicular rash appears on the
trunk and spreads to the head and the
extremities. The rash evolves from
papules to vesicles, pustules and finally
crusts. Antiviral therapy is reserved for
systemic disease in the
immunocompromised.

The four month old baby daughter of an

HIV positive mother is admitted to

hospital with seizures. She has neonatal

jaundice and microcephaly.

Correct
Cytomegalovirus inclusion disease is the
result of infection of the foetus. Many
organs may be affected and congenital
abnormalities result. Microcephaly,
seizures, neonatal jaundice,
hepatosplenomegaly, deafness and
mental retardation are some of the
features that may occur.

Theme:Skin Lesions
AAntifungal agents
BAntihistamines
CAzathioprine
DEmollients
EIsotretinoin
FLaser therapy
GPotent topical corticosteroids
HPUVA
ISystemic corticosteroids
JWide local excision
For each patient below, choose the
SINGLE most suitable treatment option
from the above list of options. Each
option may be used once, more than once
or not at all.
A 60-year-old woman with a 20 year
history of stable psoriasis has had to be
admitted for treatment three times in the
last 6 months. Her skin is now all red and
she is very unwell.

Correct

PUVA is a recognised treatment for

unstable psoriasis requiring frequent
inpatient treatment and also
erythrodermic psoriaris. It is potentially
carcinogenic and should be avoided in
patients under 18 years.

A 7-year-old girl is brought to see you

because she has red patches in her
cubital and popliteal fossae which are not
itchy. Her mother suffers from asthma
and her older brother has allergic
conjunctivitis.

Correct
The likely diagnosis is atopic dermatitis
the treatment for which is emollients.

A 30-year-old prospective newscaster

presents with a large red patch over her
cheek and lower jaw she has had since
infancy.

Correct
Laser therapy is now considered a highly
effective standard treatment for port
wine stains or haemangiomas. It may
also be employed in the management
spider naevi, hirsutism and tattoos.

A young aspiring pop musician comes to

you with large erythematous papules and
nodules on his face, upper chest and
upper back. You also notice cystic areas
and scarring of the skin.

Incorrect - The correct answer is

Isotretinoin
Isotretinoin (roaccutane) has
revolutionalised acne treatment and is
very effective in preventing scarring. It
may be teratogenic and a pregnancy test
and the use of contraception is
mandatory before treatment.

A 40-year-old welsh woman presents

with a dark rash on her right lower leg.
She says that this has increased in size
over the last three months.

Correct
The prognosis of malignant melanoma is
directly related to the depth of tumour
invasion. Early diagnosis is the key to
cure and surgical excision is the
treatment of choice although adjuvant
therapy may be required.

Theme:Diagnosis of pruritis
Adermatitis herpetiformis
Bscabies
Cprimary biliary cirrhosis
Dlymphoma
Epsoriasis
Flichen planus
Gatopic eczema
Hurticaria
Iuraemia
Jpsychogenic
Khyperthyroidism
For each case below, choose the
SINGLE most likely cause from the
above list of options. Each option may be
used once, more than once, or not at all.

A 60-year-old vagrant presents with

generalised itching. There is widespread
excoriation marks on his trunk and arms,
with linear tracts around his wrists and
between his fingers.

Correct
Linear or curved tracts may contain
mites, eggs or faeces. Sites include finger
webs, wrists, elbows, ankles, genitalia
and breasts. Treat with malathion or
permethrin.

A 54-year-old woman complains of

pruritis and skin pigmentation. She has
been found to have anti-mitochondrial
antibodies.

Correct
The underlying diagnosis is primary
biliary cirrhosis. Anti-mitochondrial
antibodies are present in >95% of
patients. There is progressive destruction
of bile ducts, portal tract fibrosis and
cirrhosis.

A 29 year woman developed an itchy

scaly rash particularly over her wrists,
with fine white streaks overlying lesions.
Her buccal mucosa is lined with a lacy,
white pattern.

Correct
Clinical picture of lichen planus, which
may be caused by drugs (thiazides, gold,
phenothiazines, quinidine, antimalarials,

sulphonamides, b-blockers,
penicillamine) or graft versus host
disease.

A 20-year-old man complains of a recent

onset of itching, following a viral
infection. There is wealing of the skin
after he has scratched it, which can last
for up to an hour.

Incorrect - The correct answer is

urticaria
Urticaria is a transient swelling of skin,
caused by vasodilatation and
accumulation of tissue fluid in the
dermis.

A 60-year-old man complains of tired,

lethargy and pruritis. He also has
nocturia and polyuria, with nausea and
vomiting. Examination revealed pallor,
pigmentation and fluid overload.

Correct
Uraemic symptoms include fatigue,
breathlessness, ankle swelling, anorexia,
vomiting, nocturia and pruritis.
Examination can reveal pigmentation,
pallor and brown nails.

Everything you want to know about

pruritis...
Theme:Fungal Skin Infections
ACandida
BFavus

CKerion
DOnychomycosis
EPityriasis versicolor
FTinea capitis
GTinea cruris
HTinea maanum
ITinea pedis
JTinea incognito
For each patient below, choose the single
most likely diagnosis from the above list
of options. Each option may be used
once, more than once or not at all.
A 17-year-old boy presents with multiple
hyperpigmented scaly macules on the
back, chest and upper arm.

Correct
Pityriasis versicolor is caused by the
fungus Malasezia furfur. The rash
usually starts after adolescence and may
be more obvious in pale skin when the
surrounding skin is tanned. In darker
skin the lesions are hypopigmented. The
fungus flouresces yellow to Wood's
lamp.

A 55-year-old man presents with pain,

itching and scaling in the third and fourth
toe webs of both feet.

Incorrect - The correct answer is

Tinea pedis
Tinea pedis is the commonest fungal
infection worldwide. The primary lesions
consist of maceration, scaling, occasional
vesicles and fissures between and
underneath the toes. Any or all of the toe
webs may be affected although the most
affected web space is the fourth